Tinnitus Birmingham Membership Application Form

BIRMINGHAM AND DISTRICT TINNITUS GROUP Registered Charity Number 1055001 Membership Application/ Donation Form *(denotes required field)

I would like to pay by: ChequePaypal* (opens new page for submission) If paying by cheque, please fill out and print this form to post

First Name/Surname:
Address Line 1*:
Address Line 2:
Address Line 3:
Town / City*:
County*:
Postcode*:

Telephone Day*/ Eve:

E-mail*:




Plus Donations to research etc.	£
TOTAL	£



If Paying by Cheque, please make payable to 'Birmingham Tinnitus Group' and after filling in the form, please use the print function below and post form to:

	The Membership Secretary B&DTG 3 Pilkington Avenue Sutton Coldfield Birmingham B72 1LA

Important Do you pay tax and are you a resident of the U.K? If you can answer yes to both of these questions please tick the box below. This will allow us to claim back further money from the Tax Office without any costs to yourself. Thank You. Tick here